Health anxiety
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l774 (Published 12 March 2019) Cite this as: BMJ 2019;364:l774
- Erik Hedman-Lagerlöf, associate professor1,
- Peter Tyrer, emeritus professor of community psychiatry2,
- John Hague, member of clinical executive of Ipswich and East Suffolk Clinical Commissioning Group, general practitioner3,
- Helen Tyrer, senior clinical research fellow2
- 1Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
- 2Centre for Psychiatry, Imperial College, London, UK
- 3Derby Road Practice, Ipswich, UK
- Correspondence to: E Hedman-Lagerlöf kire.hedman{at}ki.se
What you need to know
Consider health anxiety if the patient reports excessive worry about health that causes suffering and impairment
Avoid routinely reassuring the patient that all is well. Instead, acknowledge that that patient is worried and suggest seeking ways to address this.
Cognitive behaviour therapy focused on health anxiety is an effective treatment
A 46 year old man visits his general practitioner worried about episodes of chest pain and tightness. A recent CT coronary angiogram was normal. He has had numerous appointments with different GPs over the past year for a variety of symptoms that seem to settle down after reassurance or further investigation.
Normal concern about our health can sometimes turn into a persistent and excessive fear of being seriously ill. This is often referred to as health anxiety. In this article we offer practical tips to help clinicians identify and help people with persistent and disabling health anxiety, based on available evidence and our own clinical experience.
What you should cover
When to consider health anxiety
Health anxiety is common, with prevalence estimated at up to 20% in medical settings.1 Somatic symptom disorder and illness anxiety disorder replaced the term hypochondriasis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),1 but the less pejorative term health anxiety is typically favoured in practice. Whichever term is used, the central questions for the clinician to answer are whether the patient’s worry is excessive in relation to the actual risk and what impact is this having on their life. These patients undergo more tests and examinations and use more health service resources than those without health anxiety.2 Although children can experience health anxiety,3 it typically begins in adulthood and follows a chronic but fluctuating course. Having a medical disease or diagnosis does not exclude health anxiety1—many people have both.
Clues that may prompt further inquiry about health anxiety include:
Worry about health that quickly and repeatedly resurfaces after reassurance. This was demonstrated in a study of 60 adults reassured that there was nothing seriously wrong after attending an endoscopy clinic.4 In those with high levels of health anxiety, worry about their health and illness belief resurfaced 24 hours after their endoscopy and was sustained at one year follow-up; those with low health anxiety had immediately reduced levels of worry and illness belief, that was maintained at one year
Frequent attendance
Spending excessive time online searching for health related information, sometimes described as cyberchondria. This may lead to increased anxiety and distress as it can increase the risk that normal bodily sensations are interpreted as signs of serious somatic disease56
Health worries that lead to substantial functional impairment.
How to discuss health anxiety in the consultation
Allow the patient to express their symptoms in full without interruption—this helps them to feel that they have been listened to and taken seriously. Use the following questions to establish whether the patient has health anxiety.
Have you been worrying a lot about this? Do you tend to worry about your health in general? Do you think that you have not been taken seriously by doctors in the past? Someone with health anxiety is likely to answer yes to at least one of these.
What is the worst thing you fear could happen? This can help you to understand what is driving the fear.
When did you start to worry more about your health? Triggers might be a serious disease they or a family member were diagnosed with, the death of a loved one, or other external stresses.
How has this worry about your health affected your work, social, and family life? A hallmark of pathological health anxiety is that it leads to excessive checking and health monitoring, and creates great suffering through intolerable anxiety.
People with health anxiety tend to be very attentive not only to bodily sensations but also to medical information, which is easily misinterpreted. Hours can be spent looking at skin blemishes, measuring pulse rate and blood pressure, asking relatives for reassurance, and searching online. These preoccupations typically fail to provide an explanation for their symptoms and make anxiety worse. Many start avoiding certain places or activities that trigger bodily sensations (such as hospitals, cemeteries, physical exercise). These avoidance behaviours can reduce quality of life and maintain health anxiety in the long run.
A brief screening tool for health anxiety, such as the Bodily Preoccupation Scale of the Illness Attitude Scales (box 1), can help to identify those with severe health anxiety.8
Screening for health anxiety with the Bodily Preoccupation Scale of the Illness Attitude Scales78
Ask the patient to respond to the questions below using options “No,” “Rarely,” “Sometimes,” “Often,” or “Most of the time”
When you read or hear about an illness, do you get symptoms similar to those of the illness?
When you notice a sensation in your body, do you find it difficult to think of something else?
When you feel a sensation in your body do you worry about it?
Scoring and interpretation
No = 0, Rarely = 1, Sometimes = 2, Often = 3, Most of the time =4 (total scale range 0-12).
A score of ≥6 discriminates severe health anxiety from the general population with 92% sensitivity and 90% specificity
Explore comorbid symptoms
Many people with health anxiety have a comorbid mental health problem, summarised in box 2. If you identify an additional mental health problem, discuss which is causing most distress and which the patient would like to address first.
Differential diagnosis of health anxiety
Health anxiety—Excessive worry about health that leads to functional impairment
Generalised anxiety disorder—Worry in several domains (such as financial or job related worry)
Obsessive-compulsive disorder—Rituals in response to intrusive thoughts dominate the clinical picture
Panic disorder—Recurrent acute panic attacks
Medically unexplained symptoms—Symptoms (such as pain or tremor) are the main problem, whereas in health anxiety it is the fear of serious disease
What you should do
Someone with persistent and disabling health anxiety can be helped through developing a shared understanding of the problem with the clinician, psychological therapies, and, in some circumstances, medication.
Avoid reassurance
Reassurance to patients with health anxiety is like an addictive drug—it provides immediate relief but wears off quickly,49 sometimes even by the end of the consultation. Instead, the clinician might say, “It is clear that you are worried about your health; we have ways of helping this, and this will not affect any other treatment you are receiving.” The final clause is important as patients sometimes feel that if they admit to health anxiety their other medical problems will be ignored or minimised.
Validate symptoms
Acknowledge that you believe that their symptoms are real and genuinely experienced. By concentrating on worry as the most important symptom and recognising how unpleasant serious worry can be, you can validate the patient’s feelings and increase motivation for treatment.
Provide an alternative explanation
An important task for the clinician is to explain to the health anxious patient that a range of sensations—in the present case palpitations, chest pain, and tightness in the chest—can be symptoms of anxiety rather than disease. We often explain to patients that health anxiety is like a false alarm: fear is our body’s alarm that helps us to survive when there’s a threat; in the case of health anxiety, the body’s alarm system goes off even when there is no actual threat. Another tool we use, is to recognise that our bodies are naturally “noisy” and most sensations are not symptoms of severe disease. Follow this up with written information that includes an explanation of health anxiety and initial self care advice.10
Discuss treatment options
The first choice of treatment should be cognitive behaviour therapy.1112 In England health anxiety treatment should be available through Improving Access to Psychological Therapies (IAPT) services.13 GPs may have a role in advising non-medical therapists that health anxiety is the issue to be treated and that further physical investigations should not delay this.
Antidepressants may be considered for patients with debilitating health anxiety who are interested in treatment but who decline talking therapies.1415 Fluoxetine and paroxetine have been shown to be more effective than placebo in reducing health anxiety, but there are few randomised trials, generally with small sample sizes and high drop-out rates.16
Check understanding and arrange follow-up
Misinterpretation is a core feature of health anxiety, both of bodily sensations and health information. To minimise the risk of this in the consultation, ask the patient to summarise what you’ve discussed.
One or more follow-up appointments is likely to be helpful, to address questions that arise after the consultation and monitor progress.
Education into practice
How would you discriminate between normal worry about a symptom and health anxiety?
Where would you refer a patient who is interested in psychological treatment for health anxiety?
How this article was created
The authors include researchers in the field of health anxiety, and a GP with experience in commissioning mental health services. We searched PubMed for systematic reviews and randomised controlled trials on treatment of health anxiety and screening tools.
How patients were involved in this article
A patient with severe health anxiety who is receiving care from PT and HT after six years of incapacitating health anxiety was an adviser for this article. He has noted in particular that the comment “There is nothing wrong with you,” is remarkably unhelpful and that persistent reassurance only makes him attend more frequently.
Footnotes
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: EH-L and HT have authored books about cognitive behaviour therapy for health anxiety.
Provenance and peer review: Commissioned; externally peer reviewed.